acetabular fracture

1. Acetabular fracture
Dr P. ROHIT RAJ
MBBS MS ORTHO
ASSISTANT PROFESSOR
ORTHOPAEDIC DEPARTMENT
VISHWABHARATHI MEDICAL COLLEGE

2. • Acetabular fractures are a type of pelvic fracture, which may also
involve the ilium, ischium, and/or pubis depending on fracture
configuration.

3. Epidemiology
• Acetabular fractures are uncommon.
• The reported incidence is approximately 3 per 100,000 per year.
• This study reported a 63% to 37% male to female ratio

4. Mechanism
•fractures occur in a bimodal distribution
•high energy trauma in younger patients (e.g.,
motor vehicle accidents)
•low energy trauma in elderly patients (e.g., fall
from standing height)

7. Type of # depends upon position of femoral head in
acetabulum and magnitude of force
A

8. Anatomy
 Can be conceptualized as
being built from essentially
six principal components
 Anterior column
 Posterior column
 Anterior wall
 Posterior wall
 Acetabular dome or tectum
(Latin for roof)
 Medial wall
 Provides coverage to
approximately 170° of the
femoral head

9. 
Ant column

 Ant half of the iliac crest
 Iliac spines
 Ant half of acetabulum
 Pubis
Post column
 Ischium
 Ischial spine
 Post half of acetbulum
 Dense bone forming schiatic notch

10. Neurovascular structure
 Sciatic nerve
 Frequently injured with
Post. # dislocation
 Sup. Gluteal artery
and Nerve
 Corona mortis –
“Circle of Death”

11. Vascular-corona mortis
• anastomosis of external iliac (epigastric) and internal iliac (obturator)
vessels
• at risk with lateral dissection over superior pubic ramus

13. 
Letournal & Judet
 Simple types
 Antwall
 Antcolumn
 Post wall (most common)
 Postcolumn
 Transverse
 Associated types
 Ttype
 Post column +wall
 Transverse + postwall
 Ant column + posthemitransverse
 Bothcolumn

14. Posterior wall # Posterior column #

15. Anterior wall # Anterior column #

16. Transverse #

17. Posterior column and
posterior wall #
Transverse and posterior
wall #

18. T – shaped #Ant. Column and post.
Hemitransverse #

19. Both column #

21. Signs and symptoms
 History – cause of injury
 ATLS protocol (Advanced
trauma life support)
 Visceral injuries common
 Associated fractures common
 Elderly pt. (underlying cardiac or
neurologic condition)
 Assess and document NV status

22. Signs and symptoms
 Shortening present if hip is dislocated
 Flexion, adduction, and internal rotation
of the hip may not be present

23. Assessment – ATLS
protocol
History
• Mechanism of injury
• Ask for position of hip
• Ask of axial loading or
direct injury
• Low energy trauma
• Underlying illness
• Examination
• Open wounds
• Morel- Lavallee lesions
• Shortening
• Attitude of limb
• Neurological examination
• Document sciatic nerve
• palsy

24.  X ray pelvis AP view

 Medial roofarc
Judet views
 45 degree Iliac oblique view-affected side
touching cassette
 Shows Ant wall & post column
Post roof arc
 45 degree obturator oblique view-affected
side away from cassette
 Shows post wall & ant column
 Ant roof arc

26. Radiology of acetabular fractures
Superior weight bearing
surface

27. Landmarks of standardAP radiograph
of hip
1.liopectineal line
2.Ilioischial line
3.Radiographic teardrop
4.Roof of acetabulum.
5.Edge of anterior lip of
acetabulum
6.Edge of posterior lip
of acetabulum.

28. Obturator oblique view
• Obturator
foramen
• Anterior column
• Posterior lip or
wall of the
acetabulum

29. Iliac oblique view
• Iliac wing in its
largest dimension
• Posterior column

31. Central fracture-dislocation of the acetabulum
• X-ray showing a
fracture of the right
acetabulum with
central dislocation
of the femoral head.
• Right ilioischial and
iliopectineal lines
are completely
disrupted.

32. Central fracture-dislocation of the acetabulum

33. 

Invaluable
Thin cut(3mm)

35. 3-D CT
 Better
understanding of
the fracture
patterns.
 Planning the operative
approach
 Ability to subtract
unwanted structures

36. Management
The goal of the treatment is
restoration of articular surface,
prevent post traumatic arthritis and
to mobilise the patient as early as
possible

37. Management
 Initial treatment – follow ATLS protocols
 Operative treatment are usually not
performed as an emergency
 Closed reduction of hip
dislocations should be performed
 Skeletal traction
 Allow soft tissue healing initially
 Maintain limb length
 Maintain femoral head reduction

38. Patients factors
 Age
 Pre injury activity level
 Medical comorbidities
 Associated injuries
 Functional demands

39. Non-operative Indications
 Hip stable and congruous.
 Patient factors
 Medical contraindications
 Severe osteoporosis in elderly
 Undisplaced/Minimally displaced fractures
 Fractures with secondary congruence (both-column)
 Preexistent arthritis of hip
 Local soft tissue problems
 Morel Lavelle’ lesion
 Open wound
 Suprapubic catheter (C/I to Ilioinguinal and Stoppa)

41. Morel Lavalle lesion
 Localized area of subcutaneous fat necrosis
over the lateral aspect of the hip
 Operating through it has been associated with
a higher rate of postoperative infection

42. Non operative Treatment
 Bed rest is necessary in the acute injury
phase only
 Mobilization
 Patients should begin with touch-down partial
weight-bearing
 Gradually progress to full weight bearing when
there is adequate fracture healing, usually by 6
to 12 weeks

43. Operative Treatment
 Instability
 Incongruity.

44. Instability
 Usually associated with posterior
fracture types
 Less commonly anterior

45. Incongruity
 The curve of femoral head should fit
exactly in to dome of acetabulum in
all three radiographic views

46.  Emergency if

 Open
 Irreducible hip dislocation associated
 Vascular compromise
 Progressive schiatic nerve deficit
 Ipsilateral femoral neck fracture
Ideal within 5-7 days

49. approaches
• anterior
• ilioinguinal
• iliofemoral
• modified stoppa
• posterior
• Kocher-Langenbach
• combined
• extended ilifemoral

50. Kocher-Langenbeck approach

51. Ilioinguinal approach

52. Extended Iliofemoral approach

53. Modified Stoppa Approach

54. Posterior wall fractures

59. Transverse #

63. Anterior column

68. 
Older patients
 Intraarticular comminution
 Full thickness loss of cartilage
 Femoral head impaction
 Acetabular dome impaction
 Femoral neck #
 Preexistent arthritis

73. Post operative care
 Suction drain
 Antibiotic for 48 – 72 hours
 Thromboprophylaxis- Mechanical
compressive device with LMWH
 Indomethacin 25 mg tds beginning within 24
hours of surgery and continued for 4 to 6
weeks to prevent HO
 Passive motion of the hip on the 2nd or 3rd
day.
 Touch down ambulation & crutches on 2nd
to 4th day
 Progression to FWB must be tailored to the
individual

74. Complications
• Early:
 Mortality (0-3.6%)
 Thromboembolism
 Infection
 Neurological injury
 Vascular injury
 Intraarticular
hardware
 Malreduction
 Loss of reduction
Late:
 Avascular necrosis
 Heterotopoic
ossification
 Pseudoarthrosis
 Post traumatic
arthritis

75. Complications
 Thromboembolism
 Risk of PE 1%- 5 %
 Use of intermittent compression device plus
a form of chemical anticoagulation (eg-
LMWH or Warfarin) recommended for
prophylaxis

76. Complications
 Infection
 1-10 % patients
 Incidence of infection related to surgeons experience
 Other factors -skin necrosis, hematoma formation, and
obesity
 Prophylactic antibiotics should be administered within 1
hour before the skin incision and continued for 24-48
hours after surgery
 Multiple suction drains should be used

77. Complications
 Nerve Injury
 Sciatic nerve
 Preoperative incidence 12-31 %
 Prevalence of postoperative sciatic nerve injury is
2– 16%
 Peroneal division commonly involved
 Management of sciatic nerve injury is expectant and
prognosis is variable
 Iatrogenic injury to the femoral nerve is very rare
with a prevalence of 0.2% to 0.4%

79. Complications
 Heterotropic ossification
 Incidence varies from 3–69%
 Related to extensile surgical exposures, male
gender, associated head injury, significant delays to
surgery, fracture type, the severity of the injury
 Rare with ilioinguinal approach
 “Significant HO” -loss of active range of motion
>20% of normal.
 Indomethacin 25 mg tds for 6 weeks or 75 mg SR
capsule OD for 6 weeks
 Radiation therapy- 7–8 Gy in a single dose or 10
Gy in five doses

80. 

Class 1 is described as islands of bone within the soft
tissues about the hip
Class 2 includes bone spurs originating from the pelvis
or proximal end of the femur, leaving at least 1 cm
between opposing bone surfaces


Class 3 consists of bone spurs originating
from the pelvis or proximal end of the femur,
reducing the space between opposing bone
surfaces to less than 1 cm
Class 4 shows apparent bone ankylosis of the
hip

83. Complications
 Posttraumatic Arthritis
 Prevalence of osteoarthritis 4–48%
 Quality of the fracture reduction main
determinant
 Incidence following perfect reduction was
10%
 Anatomical reduction and restoration of joint
congruency is the best prophylaxis